Laserfiche WebLink
1//7 <br /> / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0F OFFICE USE: 1601 E. Hazelton- Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7 7 w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued _2,16-,7-7 <br /> ii <br /> . (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. , This application is made in compliance' with San Joaqui <br /> County Ordinance -No... 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION p ,1 ` ' ��oA.C7 - s c., �c w. CENSUS TRACT S <br /> ' <br /> � <br /> Owners Name y/�/N d �/ S Phone s S` <br /> Address 3 �.4 ; C �� v GT City-,j�?'�g�-5i <br /> Contractor's name _—Licendi ?yZ 03 <br /> . TYPE OF WORK (Check) : NEW WELL /.f-�DEEPENI'/ / RENDITION-/—/- DESTRUCTION /-7 _ <br /> PUMP INSTALLATION;=/�' / PL`MP REPAIR / / PUMP REPLACEMENT /_7 <br /> - G <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD \,CESSPOOL/SEEPAGE PITT{, OTHER <br /> INTENDED USE TYPE OF WELL : 1,CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Took' -'D.ia..-sof Wel-1,---Excavation p <br /> Domestic/private s Drilled of Well Casing <br /> / - ---� <br /> Dom�stic/public Driven �. y Gauge of Casing <br /> Irrigation Gravel Pack •- Depth of Grout Seal t? <br /> 0thjr Rotary - Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor _�/#/�r-i�_y_/��t-lr� ^� s •/��.c y" <br /> f <br /> Type of Pump --___- i 5 u .r-r .r.z.s/n e r' --,_ H.P• <br /> PUMP REPLACEMENT: / /' State Work Done <br /> PUMP '"tBpAIR.� - % / T State Work Done <br /> ,i DF,RTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Stat of"C forma pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> }4 after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of .the well and notify them before putting the well in use. The above , <br /> information is tr to the best of my knowledge and belief. <br /> SIGNED _,�?ed=aZ4TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I ( s <br /> APPLICATION ACCEPTED BY At DATEI mi <br /> ADDITIONAL COMMENTS: <br /> x PHASE IINS ECTIOT II / AL INSPECTION <br /> INSPECTION BY V DATE INSPEC ON DATE <br /> CALL FOR A GROiUT_INSPECTION.,PRIOR..TO GROUTINGrAND} FINAL INSPECTION. <br /> E H 1426 T K//7AZHr `- <br />